Drug Handling in a Paediatric Intensive Care Unit – Can Errors be Prevented by a Three-Step Intervention?

Abstract

Background:

Drug handling in paediatric intensive care units (PICU) is prone to medication errors. We aimed to identify type and prevalence of those errors and to assess preventative interventions.

Methods:

Prospective intervention study investigating a 3-step intervention for preventing errors in drug handling in a 10-bed PICU of a university hospital. Nurses’ drug handling was mon­itored in daily routine to identify the number of patients affected by errors and overall prevalence and types of errors in drug handling. We implemented a comprehensive intervention consisting of an information handout, a training course, and a 76-page reference book tailored to reduce the prevalence.

Results:

The prevalence of errors in drug han­dling decreased from 83% (555 errors/668 pro­cesses) to 63% (554/883; p<0.001) after the intervention. The number of affected patients remained unchanged (95% vs. 89%, p=0.370). Peroral (PO) drugs (1.33 errors/process) were more error-prone than intravenous (IV) drugs (0.64), despite being used less frequently (27% vs. 73% of all processes, p<0.001). The interventions decreased the prevalence to 0.77 errors/process (p<0.001) in PO and to 0.52 in IV drugs (p=0.025).

Conclusion:

Errors in drug handling were alarmingly frequent. PO drugs were frequently subject to errors, even though being used less frequently. The implementation of a comprehensive intervention succeeded in reducing the prevalence of errors. Yet further refinements are necessary to decrease also the number of affected patients.

Zusammenfassung

Hintergrund:

Die Arzneimittelanwendung auf pädiatrischen Intensivstationen (ITS) ist anfällig für Medikationsfehler. Ziel der Studie war es, Art und Prävalenz solcher Fehler zu identifizieren und präventive Maßnahmen zu untersuchen.

Methode:

Prospektive Interventionsstudie mit einer 3-stufigen Intervention zur Prävention von Fehlern bei der Arzneimittelanwendung auf einer pädiatrischen ITS (10 Betten) eines Universitätsklinikums. Das Pflegepersonal wurde bei der täglichen Arzneimittelanwendung beob­achtet, um die Anzahl von Patienten mit fehlerhafter Arzneimittelanwendung sowie die Prävalenz und Art der Fehler zu identifizieren. Zur Prävention wurde eine 3-stufige Intervention bestehend aus einem Informationshandout, einer Schulung sowie einem 76-seitigen Nachschlagehandbuch entwickelt.

Ergebnisse:

Die Fehlerprävalenz bei der Arzneimittelanwendung nahm von 83% (555 Fehler in 668 Prozessen) auf 63% (554/883; p<0.001) nach der Intervention ab. Die Anzahl der Patienten mit mindestens einem Fehler blieb unverändert (95% vs. 89%, p=0.370). Perorale (PO) Arzneimittel (1.33 Fehler/Prozess) waren fehleranfälliger als intravenöse (IV) Arzneimittel (0.64), obwohl sie seltener angewendet wurden (27% vs. 73% von allen Prozessen, p<0.001). Die Intervention reduzierte die Prävalenz auf 0.77 Fehler/Prozess (p<0.001) bei PO und auf 0.52 bei IV Arzneimitteln (p=0.025).

Schlussfolgerung:

Fehler bei der Arzneimittelanwendung auf einer pädiatrischen ITS sind alarmierend häufig. PO Arzneimittel sind besonders fehleranfällig, obwohl sie seltener angewendet werden. Die Implementierung einer 3-stufigen Intervention reduzierte die Prävalenz der Fehler. Eine Weiterentwicklung ist jedoch notwendig, um auch die Anzahl der betroffenen Patienten zu reduzieren.

Key words

drug administration - medication error - paediatric intensive care unit - intervention study - healthcare quality assurance

Schlüsselwörter

Arzneimittelanwendung - Medikationsfehler - pädiatrische Intensivstation - Interventionsstudie - Qualitätssicherung

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